snark: a (well-deserved) attitude of mocking irreverence and sarcasm

January 06, 2017

Ex-Governor Kitzhaber is back! Not that he ever really left Oregon, but since his resignation in 2015 Kitzhaber hasn't been very visible.

Gradually, though, he's been popping up again in the public eye, as noted in an August 2016 Willamette Week story, "The Rehabilitation of John Kitzhaber Continues," which was about his participation in a Portland health care policy conference.

As noted in a 2009 blog post whose title was the name of a position paper I wrote during my health policy days, "Quality of Life in Allocating Health Care Resources," I got to know Kitzhaber when he was President of the Oregon Senate and I was executive director of Oregon Health Decisions.

Imposing title for a blog post. It may sound kind of boring, but before we die each of us -- more than likely -- is going to face the bioethical question, "What kind of life is worth living, and at what cost?"

Back in the 1980s I lived and breathed health policy issues. That was my job. Also, my passion.

Recently I got to reminiscing about the days when I worked with Portland psychiatrist Ralph Crawshaw and Senate president John Kitzhaber (who later became Oregon's governor) on a project that laid the foundation for the Oregon Health Plan.

Getting into spring cleaning, at my wife's urging I started going through some boxes in the garage that held old memories. Out popped some Oregon Health Decisions publications -- an organization that I helped found, and was executive director of for several years.

It had been a long time since I'd seen "Quality of Life in Allocating Health Care Resources," which I wrote in 1988 on behalf of a Citizens Health Care Parliament. Reading it with fresh eyes, I was amazed at how the issues Oregon and the nation wrestled with then are the same issues being debated now.

Well, that now wasn't only 2009. It also is 2017, because the health care issues talked about at the Salem City Club meeting today were pretty much the same ones being grappled with back in the 1980s.

Accessibility. Quality. Cost.

Each of the panelists spoke well and knew what he was talking about. But to me, Kitzhaber was the star of the show. Clad in his trademark blue jeans and big cowboy belt buckle, Kitzhaber both looked great (he was born a year and a half before me, so, yeah, he's old) and talked clearly in his usual wonky, yet precise, style.

Kitzhaber still has a lot to offer Oregon, especially in the health care arena. And with the Republicans in Congress threatening to dismantle the Affordable Care Act/Obamacare, arguably our state needs him now more than ever.

I was pleased to hear O'Brien use the term Trumpcare for the currently-mythical replacement for Obamacare. I recall that one of the panelists noted that just as Obama was held responsible for everything that happened in health care after the Affordable Care Act passed, so will Trump be held similarly responsible after he and Congress do whatever they're going to do with an Obamacare replacement.

I didn't take notes during the hour long panel discussion, which was ably moderated by Cindy Condon. Here's some of the topics that have stuck in my memory.

Cost is still a big problem, even though the Affordable Care Act has brought health insurance to 20 million people, or thereabouts. So far, we've mainly gotten health insurance reform, not health care reform. Oregon has been a leader in establishing "coordinated care organizations" for Oregon Health Plan/Medicaid recipients, but changes in the entire health care delivery system need to happen, a tough job.

Priorities have to be set in health care, but this raises the illusory fear of rationing. Illusory, because rationing always has been part of health care. It just usually is done in a haphazard way. Kitzhaber talked about how early on the Oregon Health Plan prioritized services rationally so when money wasn't available to pay for everything for everybody, the least essential services were cut first. (I included some passages on priority-setting from my report in the 2009 blog post.)

Whether Obamacare or Trumpcare, the core problem of cost will remain. Again, because both Democrats and Republicans have been focused on figuring out how to get people health insurance rather than on reforming the health care delivery system so it brings the desired product, health, to citizens at a much more reasonable cost -- as every other advanced nation has been able to do.

Single Payer Health Care seems to be the answer, but was barely mentioned today. As I walked out of the City Club meeting, I was handed a brochure by someone from PNHP, Physicians for a National Health Program Oregon. I glanced at the brochure and told the guy, "This is the answer. And nobody talked about it." He smiled and said, "Right." Probably the reason was that when Congress and Trump seem determined to repeal the Affordable Care Act, replacing it with the progressive dream of a single payer system seems absurd. Well, maybe after Trumpcare crashes and burns, the political winds will blow much more strongly in a Single Payer direction.

There's no "market" in health care today. Along this line, the panelists talked a lot about the lack of market forces. Again, I suspect this stemmed more from a recognition of political reality, than a genuine conviction that what health care needs is more competition on the basis of cost, quality, and such. Someone, I believe it was O'Brien, correctly said that the demand for medical care is inelastic. When you're sick, or really sick, the last thing you're thinking about is "Where can I get the best deal on a heart bypass?" Or whatever. And the Affordable Care Act already is sort of a market, since the idea is that people can choose from among competing health insurance plans that offer comparable benefits.

Kitzhaber wants Congressional Democrats to work with Republicans on an Obamacare replacement. This might help explain why he spoke more often about market forces than I expected. Probably that's the buzzword which appeals to conservatives in Congress, and Kitzhaber might be able to play a role in bringing D's and R's together on a health care reform proposal. Kitzhaber said that he hoped Democrats wouldn't do what Mitch McConnell did to Obama after he was elected: fight him on everything.

I'm torn on this.

My inclination is that Democrats shouldn't do anything to help Republicans do their repeal and replace thing. If they want to take Affordable Care Act coverage from many millions of Americans, Republicans need to own the consequences. Notably, lots of pissed-off people.

Republicans made a big deal out of Obama supposedly not fulfilling his "if you like your current coverage, you can keep it" pledge. But it would be a hugely bigger deal if Trump takes health insurance away from people who currently have it, and then doesn't replace it with anything.

People will suffer. People will go bankrupt from medical bills they can't pay. And yes, some people will die because of a lack of health care.

So I can understand why Kitzhaber wants Democrats to work with Republicans. If Dems can make an Obamacare replacement more effective than it would otherwise be, this would be a good thing for people who rely on the Affordable Care Act for medical care.

Yet this would have some political drawbacks.

A bipartisan Obamacare replacement plan would leave Democrats owning the consequences of it, along with Republicans. And there's a decent argument to be made that if the nation's health care system gets worse -- maybe much worse -- under conservative governance, this would improve the chance of a single payer plan, or something close to it, being implemented under a Democratic president elected in 2020.

I came away feeling better about how Oregon has been, and will be, handling health care in this state. It's the crazy goings-on in Washington, D.C. that's worrisome. I've got little confidence that the Trump administration can handle anything well, including our country's health care system.